Clinical Utilization Management Guidelines
|
|
- Beatrice Paul
- 5 years ago
- Views:
Transcription
1 BadgerCare Plus This is an update about information in the provider manual. For access to the latest manual, go online to Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division effective September 1, Highlighted sections indicate a new or revised guideline. To see the full list of Clinical UM Guidelines, visit the Medical Policies and Clinical UM Guidelines page. The Medical Operations Committee also adopted the Interqual Coronary Bypass Procedures Criteria for use in review of the 1-2 vessel coronary artery bypass grafting (CABG) procedures on September 11, Guideline number CG-ADMIN- 01 CG-ANC-04 CG-ANC-05 CG-ANC-06 CG-BEH-01 CG-BEH-02 CG-BEH-03 CG-BEH-04 CG-BEH-05 CG-BEH-07 CG-BEH-09 CG-BEH-10 CG-BEH-11 CG-BEH-12 CG-BEH-13 CG-BEH-14 CG-DME-01 CG-DME-03 CG-DME-05 CG-DME-07 Clinical UM Guideline name/title Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Necessity Determinations When No Other Clinical UM Guideline Exists Ambulance Services: Air and Water Ambulance Services: Ground; Emergent Ambulance Services: Ground; Non-Emergent Assessment for Autism Spectrum Disorders and Rett Syndrome Adaptive Behavioral Treatment for Autism Spectrum Disorder Psychiatric Disorder Treatment Substance-Related and Addictive Disorder Treatment Eating and Feeding Disorder Treatment Psychological Testing Assertive Community Treatment (ACT) Basic Skills Training/Social Skills Training Mental Health Support Services Psychosocial Rehabilitation Services Targeted Case Management (TCM) Intensive In-Home Behavioral Health Services External (Portable) Continuous Insulin Infusion Pump Neuromuscular Stimulation in the Treatment of Muscle Atrophy Cervical Traction Devices for Home Use Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) In Eastern Wisconsin, Anthem Blue Cross and Blue Shield is the trade name of Compcare Health Services Insurance Corporation (for its insurance policies offered through the BadgerCare Plus and Medicaid SSI programs), an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. WEBPAWI
2 Page 2 of 5 CG-DME-08 Infant Home Apnea Monitors CG-DME-09 Continuous Local Delivery of Analgesia to Operative Sites using an Elastomeric Infusion Pump During the Post-Operative Period CG-DME-10 Durable Medical Equipment CG-DME-12 Home Phototherapy Devices for Neonatal Hyperbilirubinemia CG-DME-13 Lower Limb Prosthesis CG-DME-15 Hospital Beds and Accessories CG-DME-16 Pressure Reducing Support Systems Groups 1, 2 & 3 CG-DME-18 Home Oxygen Therapy CG-DME-19 Therapeutic Shoes, Inserts or Modifications for Individuals with Diabetes CG-DME-20 Orthopedic Footwear CG-DME-21 External Infusion Pumps for the Administration of Drugs in the Home or Residential Care Settings CG-DME-22 Ankle-Foot & Knee-Ankle-Foot-Orthotics (Braces) CG-DME-23 Lifting Devices for Use in the Home CG-DME-24 Wheeled Mobility Devices: Manual Wheelchairs Standard, Heavy Duty, Lightweight CG-DME-25 Seat Lift Mechanisms CG-DME-31 Wheeled Mobility Devices: Wheelchairs Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) CG-DME-33 Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories CG-DME-35 Breastfeeding Pumps CG DME-36 Pediatric Gait Trainers CG-DME-37 Air Conduction Hearing Aids CG DME-38 Continuous Interstitial Glucose Monitoring CG-DME-39 Dynamic Low-Load Prolonged-Duration Stretch CG-DRUG-01 Off-Label Drug and Approved Orphan Drug Use CG-DRUG-03 Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis Use of Low Molecular Weight Heparin Therapy, Fondaparinux (Arixtra ) and CG-DRUG-04 Direct Thrombin Inhibitors in the Outpatient Setting CG-DRUG-05 Recombinant Erythropoietin Products CG-DRUG-07 Hepatitis C Pegylated Interferon Antiviral Therapy (Archived 04/05/16) CG-DRUG-08 Enzyme Replacement Therapy for Gaucher Disease CG-DRUG-09 Immune Globulin (Ig) Therapy CG-DRUG-11 Infertility Drugs CG-DRUG-13 Hepatitis B Interferon Antiviral Therapy CG-DRUG-15 Gonadotropin Releasing Hormone Analogs CG-DRUG-16 White Blood Cell Growth Factors Progesterone Therapy as a Technique to Prevent Preterm Delivery in High-Risk CG-DRUG-19 Women CG-DRUG-20 Enfuviritide (Fuzeon) CG-DRUG-21 Naltrexone (Vivitrol ) Injections for the Treatment of Alcohol and Opioid
3 Page 3 of 5 Dependence CG-DRUG-24 Repository Corticotropin Injection (H.P. Acthar Gel) CG-DRUG-27 Clostridial Collagenase Histolyticum Injection CG-DRUG-28 Alglucosidase alfa (Lumizyme, Myozyme ) CG-DRUG-29 Hyaluronan Injections in the Knee CG-DRUG-30 Oprelvekin (Neumega) CG-DRUG-33 Palonosetron (Aloxi ) CG-DRUG-34 Docetaxel (Docefrez, Taxotere ) CG-DRUG-38 Pemetrexed Disodium (Alimta ) CG-DRUG-40 Bortezomib (Velcade ) CG-DRUG-41 Zoledronic acid CG-DRUG-42 Asparagine Specific Enzymes (Asparaginase) CG-DRUG-43 Natalizumab (Tysabri ) CG-DRUG-44 Pegloticase (Krystexxa ) CG-DRUG-45 Octreotide acetate (Sandostatin ; Sandostatin LAR Depot) CG-DRUG-46 Fosaprepitant (Emend ) CG-DRUG-47 Level of Care: Specialty Pharmaceuticals CG-DRUG-48 Azacitidine (Vidaza ) CG-DRUG-49 Doxorubicin Hydrochloride Liposome Injection CG-DRUG-50 Paclitaxel, protein-bound (Abraxane ) CG-DRUG-51 Romidepsin (Istodax ) CG-DRUG-52 Temsirolimus (Torisel ) CG-DRUG-53 Drug Dosage, Frequency and Route of Administration CG-DRUG-59 Testosterone, Injectable Drug Testing or Screening in the Context of Substance Use Disorder and CG-LAB-09 Chronic Pain CG-MED-08 Home Enteral Nutrition CG-MED-21 Anesthesia Services and Moderate ("Conscious") Sedation CG-MED-22 Neuropsychological Testing CG-MED-23 Home Health CG-MED-24 Electromyography and Nerve Conduction Studies CG-MED-28 Iontophoresis for Medical Indications CG-MED-32 Ancillary Services for Pregnancy Complications CG-MED-38 Inpatient admission for Radiation Therapy for Cervical or Thyroid Cancer CG-MED-42 Maternity Ultrasound in the Outpatient Setting CG-MED-44 Holter Monitors CG-MED-45 Transrectal Ultrasonography CG-MED-46 Ambulatory and Inpatient Video Electroencephalography CG-MED-47 Fundus Photography CG-MED-48 Scrotal Ultrasound Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions CG-MED-49 (OAEs) for Hearing Disorders
4 Page 4 of 5 CG-MED-50 CG-MED-51 CG-MED-52 CG-MED-53 CG-MED-54 CG-MED-55 CG-OR-PR- 04 CG-OR-PR CG-SURG-03 CG-SURG-05 CG-SURG-08 CG-SURG-09 CG-SURG-12 CG-SURG-18 CG-SURG-24 CG-SURG-25 CG-SURG-27 CG-SURG-30 CG-SURG-31 CG-SURG-32 CG-SURG-33 CG-SURG-36 CG-SURG-38 CG-SURG-39 CG-SURG-40 CG-SURG-41 CG-SURG-42 CG-SURG-43 CG-SURG-44 CG-SURG-45 Visual, Somatosensory and Motor Evoked Potentials Three-Dimensional (3-D) Rendering of Imaging Studies Allergy Immunotherapy (Subcutaneous) Cervical Cancer Screening for Women Under 21 Years of Age Strapping Level of Care: Advanced Radiologic Imaging Cranial Remodeling Bands and Helmets (Cranial Orthotics) Myoelectric Upper Extremity Prosthesis Devices Pulmonary Rehabilitation Physical Therapy Occupational Therapy Speech-Language Pathology Services Private Duty Nursing in the Home Setting Blepharoplasty, Blepharoptosis Repair and Brow Lift Maze Procedure Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury Temporomandibular Disorders Penile Prosthesis Implantation Septoplasty Functional Endoscopic Sinus Surgery (FESS) Injection Treatment for Morton's Neuroma Sex Reassignment Surgery Tonsillectomy with or without Adenoidectomy for Children Treatment of Keloids and Scar Revision Pain Management: Cervical, Thoracic & Lumbar Facet Injections Lumbar Fusion and Lumbar Total Disc Arthroplasty (TDA) Adenoidectomy Lumbar Laminectomy, Hemi-laminectomy, Laminectomy and/or Discectomy Pain Management: Epidural Steroid Injections Cataract Removal Surgery for Adults Surgical Strabismus Correction Cervical Fusion Knee Arthroscopy Coronary Angiography in the Outpatient Setting Bone Graft Substitutes
5 Page 5 of 5 CG-SURG-46 Myringotomy and Tympanostomy Tube Insertion CG-SURG-47 Surgical Interventions for Scoliosis and Spinal Deformity CG-SURG-48 Elective Percutaneous Coronary Interventions (PCI) CG-SURG-49 Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities CG-SURG-50 Assistant Surgeons CG-SURG-51 Outpatient Cystourethroscopy CG-SURG-52 Level of Care: Hospital-Based Ambulatory Surgical Procedures, including Endoscopic Procedures CG SURG-53 Elective Total Hip Arthroplasty CG SURG -54 Elective Total Knee Arthroplasty CG-SURG-55 Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation CG-SURG-57 Diagnostic Nasal Endoscopy CG-SURG-58 Radioactive Seed Localization of Nonpalpable Breast Lesions CG-THER- RAD-01 Fractionation and Radiation Therapy in the Treatment of Specified Cancers CG-THER- RAD-02 Special Radiation Physics Consult and Treatment Procedure CG-TRANS- 02 Kidney Transplantation
BadgerCare Plus. Ambulance services: air and water Ambulance services: ground; nonemergent
Clinical Utilization Management (UM) Guidelines Effective June 15, 2016, the Clinical UM Guidelines listed below were adopted by the medical operations committee for the Government Business Division. To
More informationClinical Utilization Management Guidelines
Provider Bulletin This is an update about information in the provider manual. For access to the latest manual, go online to https://mediproviders.anthem.com/va. Clinical Utilization Management Guidelines
More informationAmbulance services: air and water Ambulance services: ground; nonemergent
Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Clinical Utilization Management (UM) Guidelines Effective October 1, 2016, the listed below were adopted by the medical operations
More informationMedical Policies and Clinical Utilization Management Guidelines
providers.amerigroup.com Medical Policies and Clinical Utilization Management Guidelines Amerigroup Community Care began using Anthem s nationally recognized, evidence-based Medical Policies and Clinical
More informationClinical Utilization Management Guidelines
Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government
More informationClinical Utilization Management Guidelines
Clinical Utilization Management Guidelines Medi-Cal Managed Care L.A. Care Medi-Cal Access Program Major Risk Medical Insurance Program The Clinical Utilization Management (UM) Guidelines on this list
More informationClinical Utilization Management Guidelines
Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for Anthem HealthKeepers
More informationClinical Utilization Management Guidelines
Medi-Cal Managed Care L.A. Care Major Risk Medical Insurance Program Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM
More informationClinical Utilization Management Guidelines First Quarter, 2017
https://providers.amerigroup.com Clinical Utilization Management Guidelines First Quarter, 2017 On March 21, 2017, the Medical Operations Committee for the Government Business Division adopted the following
More informationMedical Policies and Clinical Utilization Management Guidelines
https://providers.amerigroup.com Medical Policies and Clinical Utilization Management Guidelines Amerigroup Community Care began using Anthem s nationally recognized, evidence-based Medical Policies and
More informationMedical Policies and Clinical Utilization Management Guidelines
https://providers.amerigroup.com Medical Policies and Clinical Utilization Management Guidelines Amerigroup began using Anthem s nationally recognized, evidence-based Medical Policies and Clinical Utilization
More informationMedical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Amerigroup Kansas, Inc. began using Anthem s nationally recognized, evidence-based Medical Policies and Clinical Utilization Management (UM)
More informationMedical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies adopted for Anthem HealthKeepers Plus. The full list of Medical
More informationMedical Policies and Clinical Utilization Management Guidelines
Medi-Cal Managed Care L.A. Care Major Risk Medical Insurance Program Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies
More informationMedical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and
More informationNote: these medications are on the auto-exempt list thus they do not count toward the member script limit
September 2016 TN-NL-0030-16-B Smoking Cessation Let s help improve patients chances to successfully quit smoking. As you are aware, approximately 69% of smokers would like to quit and nearly half of them
More informationMedical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and
More informationMedical Policies and Clinical Utilization Management Guidelines
Medi-Cal Managed Care L.A. Care Major Risk Medical Insurance Program Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies
More informationMedical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and
More informationClinical Utilization Management Guidelines
The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division. To see the full list
More informationClinical Utilization Management Guidelines
https://providers.amerigroup.com Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical
More informationClinical Utilization Management Guidelines
https://providers.amerigroup.com Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical
More informationClinical Utilization Management Guidelines
https://providers.amerigroup.com Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical
More informationClinical Utilization Management Guidelines
The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division. To see the full list
More informationMedical Policies and Clinical Utilization Management Outpatient Guidelines
https://providers.amerigroup.com Medical Policies and Clinical Utilization Management Outpatient Guidelines Amerigroup Community Care began using Anthem s nationally recognized, evidence-based Medical
More informationClinical Utilization Management Guidelines
https://providers.amerigroup.com Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical
More informationClinical Utilization Management Guidelines
Medi-Cal Managed Care L.A. Care Major Risk Medical Insurance Program The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations
More informationClinical Utilization Management Guidelines update
Medicaid Managed Care The Clinical Utilization Management (UM) Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division.
More informationMedical Policies and Clinical Utilization Management Guidelines
Medicaid Managed Care Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list
More informationDate - Current Version Implementation. Date - First Implementationby - CO 7/1/ /9/2012 7/1/2013 7/1/2013 4/16/2013 4/1/2016 1/1/2013 1/1/2013
State: Nevada Anthem Blue Cross and Blue Shield Approved and adopted corporate Clinical Utilization Management (UM) Guidelines NEVADA Updated January 2, 2018 NOTE: Any Clinical Guideline not included in
More informationMedical policies update
On February 5, 2015, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following medical policies which are applicable to BlueChoice HealthPlan Medicaid. These medical policies
More informationClinical Utilization Management Guidelines
Clinical Utilization Management Guidelines Medi-Cal Managed Care L.A. Care Major Risk Medical Insurance Program The Clinical Utilization Management (UM) Guidelines below were adopted by the medical operations
More informationMedical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and
More informationClinical Utilization Management Guidelines
Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines below, which are applicable to Anthem HealthKeepers Plus members, were adopted by the medical operations committee
More informationMedical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and
More informationEffective April 7, 2014 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST IMPORTANT
Effective April 7, 2014 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST The following services require clinical review preauthorization for commercial managed care products, Medicare,
More informationPrior Authorization List Effective February 2, 2015
Prior Authorization List Effective February 2, 2015 Prior authorization is required for the following services. Prior authorization is the responsibility of the provider ordering or rendering services
More informationMedical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and
More informationApril 4, 2016 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST
A nonprofit independent licensee of the BlueCross BlueShield Association April 4, 2016 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST The following services require clinical review
More informationMedical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and
More informationState: Virginia. Clinical Guidelines Applicable for Virginia
State: Virginia Clinical Guidelines Applicable for Virginia NOTE: Any Clinical Guideline not included in this standard adopted list that is needed to complete a ASO group-specific review requirement will
More informationJan 30, Dear Provider:
Jan 30, 2015 Dear Provider: Kern Health Systems strives to provide quality and timely services to our members. Recently, KHS made changes to the services included on Prior Authorization Needed list. The
More informationClinical Utilization Management Guidelines
Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines highlighted below were adopted by the medical operations committee for on January 3, 2019. For markets with
More informationMedical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and Clinical
More informationMedical Policies and Clinical Utilization Management Guidelines
Medi-Cal Managed Care L.A. Care Major Risk Medical Insurance Program Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies
More informationMedical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and
More informationMedical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies adopted for. The full list of Medical Policies and Clinical Utilization
More informationMedical Policies and Clinical Utilization Management Guidelines
Medi-Cal Managed Care L.A. Care Major Risk Medical Insurance Program Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies
More informationMedical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical Policies adopted for Anthem HealthKeepers Plus. The full list of Medical
More informationMedical Policies and Clinical Utilization Management Guidelines
Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Clinical UM Guidelines and/or Medical
More informationClinical Utilization Management Guidelines
Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Clinical Utilization Management Guidelines The Clinical Utilization Management (UM) Guidelines below were adopted by the medical
More informationMedical Policies and Clinical Utilization Management Guidelines
Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Guidelines and/or Medical Policies the health plan has adopted. The full list of Medical Policies and Clinical
More informationMedical Policies and Clinical Utilization Management Guidelines
Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Medical Policies and Clinical Utilization Management Guidelines Attached is a list of the Guidelines and/or Medical Policies the
More information2016 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization
2016 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services
More informationProvider Alert. November 30, 2017
Provider Alert November 30, 2017 Summary of changes to the MedStar Family Choice MD HealthChoice Plan Quick Authorization Guide effective for claims received 01/01/2018 1. The following eye procedures
More informationApril 8, 2018 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST
A nonprofit independent licensee of the BlueCross BlueShield Association April 8, 2018 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST The following services require clinical review
More informationNew York Essential Plan cost-sharing matrix
New York Plan cost-sharing matrix On January 1, 2016, Empire BlueCross BlueShield HealthPlus (Empire) is offering a new comprehensive and affordable health insurance program. The Plan is a health benefit
More informationMetroPlus Health Plan SCHEDULE OF BENEFITS MetroPlus Gold
SECTION XXIV MetroPlus Health Plan SCHEDULE OF BENEFITS MetroPlus Gold COST-SHARING Deductible Individual Family Out-of-Pocket Limit Individual Family $0 $0 $7,150 $14,300 except as required for emergency
More informationAIM Specialty Health
GA Standard Preapproval CODE List (06/01/18) Eligibility and benefits Eligibility and benefits can be verified by accessing the BCBSGa/BCBSHP web site bcbsga.com or by calling the number on the back of
More informationOutpatient Specialty Referral Request Types
What is a request type? Request types are templates created for use with Health Net Federal Services, LLC s (HNFS) online referral and authorization submission tools, available at www.tricare-west.com
More informationSpecialty Referrals. Start of Code Range (Procedure Low Code) Request Request Profile Description. End of Code Range (Procedure High Code)
What is a request profile? profiles are templates created for use with specialty referral, outpatient authorization, and outpatient behavioral health service request submissions. Each request profile has
More informationAnthem Blue Cross and Blue Shield GA Standard Preapproval CODE List 4/1/2019
Anthem Blue Cross and Blue Shield GA Standard Preapproval CODE List 4/1/2019 Eligibility and benefits: Eligibility and benefits can be verified by accessing the Anthem Blue Cross and Blue Shield web site
More informationJanuary 2016 News Bulletin
January 2016 News Bulletin Claims tip of the month We encourage providers to utilize Amerigroup Washington, Inc. central resources when submitting claims disputes. Why? They are staffed to specifically
More informationMDwise Community Health Network Hoosier Healthwise Medical Services that Require Prior Authorization
MDwise Community Health Network Hoosier Healthwise Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network
More informationMedical and claim payment policy activity
Medical and claim payment policy activity Commercial business The following pages list the policy activity for commercial business that we have posted to our Medical Policy Portal from. For the most up-to-date
More informationMVP PREMIER PLUS SCHEDULE OF BENEFITS Gold 4 MVP Health Plan, Inc. Embedded Deductible Off Exchange
COST-SHARING Deductible Individual Family Prescription Drug Deductible Individual Family Out-of-Pocket Limit Individual Family OFFICE VISITS Primary Care Visits (or Home Visits) Specialist Visits (or Home
More informationMEDICAL & RX BENEFIT MATRIX. American Environmental Group/HSA Plan EFFECTIVE DATE: MEDICAL & RX BENEFITS
MEDICAL & RX BENEFIT MATRIX American Environmental Group/HSA Plan EFFECTIVE DATE: 01-01-2011 MEDICAL & RX BENEFITS SCHEDULE OF BENEFITS MEDICAL BENEFITS COVERED SERVICE/PLAN IN-NETWORK OUT-OF-NETWORK CATEGORY
More informationParticipating Provider Non- Participating Provider Limitations & Exceptions. deductible applies. 75% of the Fund's fee schedule; deductible applies
Medical Benefits for eligible Pension Members and their eligible dependents who are not Eligible for Medicare effective 1/1/2019. NOTE $50,000.00 lifetime major medical maximum effective 1/1/2013 Out-of-network
More informationSpecial Notes Implementation Date by CO. State CG number CG title CG Category Original Current Version
Anthem Blue Cross and Blue Shield Approved and adopted corporate Clinical Utilization Management (UM) Guidelines COLORADO Updated August 17, 2018 NOTE: Any Clinical Guideline not included in this standard
More informationMedical and claim payment policy activity
Medical and claim payment policy activity Commercial business The following pages list the policy activity for commercial business that we have posted to our Medical Policy Portal from January 24 February
More informationMEDICAL & RX BENEFIT MATRIX. American Environmental Group/PPO Plan HSB Customer Service: EFFECTIVE DATE: MEDICAL & RX BENEFITS
MEDICAL & RX BENEFIT MATRIX American Environmental Group/PPO Plan HSB Customer Service: EFFECTIVE DATE: 01-01-2011 MEDICAL & RX BENEFITS SCHEDULE OF BENEFITS MEDICAL BENEFITS COVERED SERVICE/PLAN IN-NETWORK
More informationClinical UM Guidelines for Indiana, Kentucky, Missouri, Ohio and Wisconsin
10/4/2018 State: State CG number CG title CG Category Date implemented CG-ADMIN-02 Clinically Equivalent Cost Effective Services Targeted Immune Modulators Admin 7/1/2018 CG-ANC-04 Ambulance services Air
More informationUnitedHealthcare Notification/Prior Authorization Requirements Effective October 1, 2016
General Information This list contains notification/prior authorization review requirements for participating care providers for inpatient and outpatient services, as referenced in the UnitedHealthcare
More informationMedical Policies and Clinical Utilization Management Guidelines update
Medical Policies and Clinical Utilization Management Guidelines update Medical Policies update Summary: On July 26, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following
More informationAnthem Blue Cross and Blue Shield Central Region 2013 Blue Products Pre-Certification List for Indiana, Kentucky, Missouri, Ohio and Wisconsin
Anthem Blue Cross and Blue Shield Central Region 2013 Blue Products Pre-Certification List for Indiana, Kentucky, Missouri, Ohio and Wisconsin OH/IN/KY Blue Products: Blue Priority SM (HMO), Blue Priority
More informationAmerican Board of Physical Medicine & Rehabilitation. Part I Curriculum & Weights
American Board of Physical Medicine & Rehabilitation Part I Curriculum & Weights Neurologic Disorders 30% Stroke Spinal Cord Injury Traumatic Brain Injury Neuropathies a) Mononeuropathies b) Polyneuropathies
More informationsad EFFECTIVE DATE: POLICY LAST UPDATED:
Medical Coverage Policy Prior Authorization via Web-Based Tool for Procedures sad EFFECTIVE DATE: 09 01 2015 POLICY LAST UPDATED: 12 19 2017 OVERVIEW This policy documents the prior authorization request
More informationNeuromuscular Electrical Stimulator (NMES) Corporate Medical Policy
Neuromuscular Electrical Stimulator (NMES) Corporate Medical Policy File name: Neuromuscular Electrical Stimulator (NMES) File Code: UM.NS.04 Origination: 05/01/2007 Last Review: 06/2018 Next Review: 06/2019
More informationService Provider Department Phone Number
Service Provider Department Phone Number A Activities of Daily Living Occupational Therapy Rehabilitation Services 734-593-5620 Adaptive Equipment - home Occupational Therapy Rehabilitation Services 734-593-5620
More informationOH, IN, KY, MO: Lumenos Health Savings Account, Lumenos Health Reimbursement Account, Lumenos Health Incentive Account
Anthem Blue Cross and Blue Shield Central Region 2018 Consumer Directed Health Plans Pre- Certification List for Indiana, Kentucky Missouri, Ohio and Wisconsin OH, IN, KY, MO: Lumenos Health Savings Account,
More informationsad EFFECTIVE DATE: POLICY LAST UPDATED:
Medical Coverage Policy Prior Authorization via Web-Based Tool for Procedures sad EFFECTIVE DATE: 09 01 2015 POLICY LAST UPDATED: 12 18 2018 OVERVIEW This policy documents the prior authorization request
More informationOH, IN, KY, MO: Lumenos Health Savings Account, Lumenos Health Reimbursement Account, Lumenos Health Incentive Account
Anthem Blue Cross and Blue Shield Central Region 2012 (Effective 3/5/2012) Consumer Directed Health Plans Pre-Certification List for Indiana, Kentucky Missouri, Ohio and Wisconsin OH, IN, KY, MO: Lumenos
More informationUnitedHealthcare Notification/Prior Authorization Requirements Effective July 1, 2017
General Information This list contains notification/prior authorization review requirements for participating care providers for inpatient and outpatient services, as referenced in the 2017 UnitedHealthcare
More informationREVENUE CODE LIST REQUIRING CPT/HCPCS CODES FOR OUTPATIENT FACILITY CLAIMS
REVENUE CODE LIST REQUIRING CPT/HCPCS CODES FOR OUTPATIENT FACILITY CLAIMS For Providers Effective July 15, 2018 Revenue Code Description 240 All inclusive ancillary, general 250 Pharmacy 251 Drugs, generic
More informationBenefit Name In Network Out of Network Limits and Additional Information. Benefit Name In Network Out of Network Limits and Additional Information
BluePoint 3 Benefit Time Period: 06/01/2015-05/31/2016 Broome County - Red HMO Plan General Information Cost Sharing Expenses Deductible - Single $0 Deductible - Two Person $0 Deductible - Family $0 Services
More informationInpatient ALL TEXAS REFERRAL / AUTHORIZATION FORMS MUST BE SIGNED BY THE PCP OR ORDERING PHYSICIAN THAT HAS A VALID REFERRAL FROM THE PCP.
Prior Authorization List for Participating Providers Effective January 1, 2018 Applies to: Parkland HEALTHfirst, KIDSfirst, CHIP Perinate and CHIP Perinate Newborn This Prior Authorization List supersedes
More informationPatient Price Information List January 1, 2018
In compliance with state law, Western Reserve Hospital is providing this price list containing our charges for Room and Board, Emergency Department, Operating Room, Physical Therapy, Pain Medicine and
More informationSchedule of Benefits - CENTRAL HMO Group CITY OF MARSHFIELD Benefit Year: January 1st through December 31st Effective Date: 01/01/2017
Security Health Plan certifies that you and any covered dependents have coverage as described in your Certificate and Schedule of Benefits as of the effective date shown on the letter you received with
More informationJanuary 2016 Topic of the Month
January 2016 Topic of the Month MedStar Family Choice Medicaid Updated Authorization Rules Effective March 1, 2016 To all of our valued practitioners of MedStar Family Choice Medicaid in Maryland and the
More informationPrior Authorization List for Physician Alliance of the Rockies, UnitedHealthcare Medicare Advantage Effective April 1, 2018
Prior List for Physician Alliance of MEDICAL MANAGEMENT CONTACT INFO- MONDAY - FRIDAY FROM 8:00 AM TO 5:00 PM - (720) 445-9404 *ALL REFERRALS TO SPECIALISTS REQUIRE PRIOR AUTHROIZATION* *ALL OUT OF NETWORK
More informationPrincipal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (7/1/18 6/30/19)
Benefit Summary 35876D 35876 SCHOOLS INSURANCE GROUP #35876 Principal Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (7/1/18 6/30/19) Plan Out-of-Pocket Maximum For Services subject
More informationProvider Newsletter. Table of Contents. Reimbursement Policy: Improve member medication regimen. Page 2
Provider Newsletter https://providers.amerigroup.com/ April 2018 Table of Contents Improve member medication regimen Page 2 Medical Policies and Clinical Utilization Management Guidelines updated Page
More informationAnthem Blue Cross Your Plan: Premier HMO 20/200 admit/100 OP Your Network: California Care HMO
Anthem Blue Cross Your Plan: Premier HMO 20/200 admit/100 OP Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process.
More informationDrug Name. J0129 Injection, abatacept (Orencia ), 10 mg Effective 01/01/2014. J0178 Injection, aflibercept (Eylea ), 1 mg Effective 04/01/2015
J0129 Injection, abatacept (Orencia ), 10 J0178 Injection, aflibercept (Eylea ), 1 J0256 J0257 J0585 J0586 J0587 J0588 J0597 J0641 J0717 J0800 Injection, alpha 1-proteinase inhibitor, human (Aralast NP,
More informationDELINEATION OF PRIVILEGES - REHABILITATION MEDICINE
KALEIDA HEALTH Name ABMS Board DELINEATION OF PRIVILEGES - REHABILITATION MEDICINE Certification: Please circle all that apply: Board Qualified: Inpatient Rehab Care: Admitting Privileges** (**e: Admitting
More informationsad EFFECTIVE DATE: POLICY LAST UPDATED:
Medical Coverage Policy Prior Authorization via Web-Based Tool for Procedures sad EFFECTIVE DATE: 09 01 2015 POLICY LAST UPDATED: 12 19 2017 FOR INTERNAL USE ONLY: An RSS was requested to remove prior
More informationAnthem Blue Cross and Blue Shield Central Region 2018 Blue Products Pre-Certification List for Indiana, Kentucky, Missouri, Ohio and Wisconsin
Anthem Blue Cross and Blue Shield Central Region 2018 Blue Products Pre-Certification List for Indiana, Kentucky, Missouri, Ohio and Wisconsin OH/IN/KY Blue Products: Blue Priority SM (HMO), Blue Priority
More informationHealthyBlue Living SM
Deductible, Copays and Dollar Maximums Deductible Fixed Dollar Copays Coinsurance Annual Coinsurance Maximum (ACM) Out of Pocket Maximum - applies to deductibles, copays and coinsurance amounts for all
More informationOregon CPT Preapproval Grid
Not Applicable Home Health Stays - For all Initial Certification and Recertification periods Notes: Initial Certification review required effective 1/1/12. Not Applicable Skilled Nursing Facility Stays
More information